An Act furthering health empowerment and affordability by leveraging transformative health care.
Whereas, The deferred operation of this act would tend to defeat its purpose, which is to further health empowerment and affordability while leveraging transformative health care, therefore it is hereby declared to be an emergency law, necessary for the immediate preservation of the public health.
SECTION1. Section 16T of chapter 6A of the General Laws, as appearing in the 2016 Official Edition, is hereby amended by adding the following subsection:-
(g)(1)The health planning council shall, subject to appropriation, assemble 5 regional health policy councils in geographically diverse areas. Each regional council shall have not more than 15 members.The members shall reflect a broad distribution of diverse perspectives on the health care system including, but not limited to, health care providers and provider organizations, including community health centers, organizations with expertise in health care workforce development, accountable care organizations, third-party payers, both public and private, local governments and schools and institutions in the communities in a council’s region.
(2) Each regional council shall: (i) identify innovations and best practices in health care within the region; (ii) identify interventions that improve population health at the regional or community level, including social determinants that impact health outcomes; (iii) identify shortages of health care resources in the region; and (iii) facilitate implementation of innovations, best practices and interventions throughout the region.
(3) Regional councils shall report annually to the health planning council on interventions, best practices and innovations that have been identified and provide information about steps that have been taken towards broader implementation throughout the region not later than August 1.
(4) The health planning council shall annually produce a summary report of the reports produced by the regional councils under paragraph (3) not later than November 1. The report shall be made available on the council’s public website and filed with the clerks of the senate andhouse of representatives, the senate and house committees on ways and means and the joint committee on health care financing.
SECTION 2.Said chapter 6A is hereby further amended by inserting after section 16Z the following section:-
Section 16AA. (a) There shall be a task force to make recommendations on aligned measures of health care provider quality and health system performance to ensure consistency in the use of quality measures in contracts between payers, including the commonwealth and carriers, and health care providers in the commonwealth, ensure consistency in methods for evaluating providers for tiered network products, reduce administrative burden, improve transparency for consumers, improve health system monitoring and oversight by relevant state agencies and improve quality of care.
The task force shall be convened by the commissioner of public health and the executive director of the health policy commission, who shall serve as co-chairs, and shall include the following members or their designees: the executive director of the center for health information and analysis; the executive director of the group insurance commission; the assistant secretary for MassHealth; the commissioner of insurance; and the following members who shall be appointed by the governor, 1 of whom shall represent The Massachusetts Hospital Association, Inc., 1 of whom shall represent the Massachusetts Medical Society, 1 of whom shall be a behavioral health provider, 1 of whom shall be a long term supports and services provider, 1 of whom shall represent Blue Cross and Blue Shield of Massachusetts, Inc., 1 of whom shall represent the Massachusetts Association of Health Plans, Inc., 1 of whom shall represent individuals with disabilities, 1 of whom shall represent consumersand 1 of whom shall be an expert in establishing health system performance measures. Members appointed to the task force shall have experience with and expertise in health care quality measurement.
The task force shall be convened annually not later than January 15 and the task force shall submit a report with its recommendations, including any changes or updates to aligned measures of health care provider quality and health system performance, to the secretary of health and human services and the joint committee on health care financing annually not later than May 1.
The task force shall make recommendations on aligned quality measures for use in:(i) contracts between payers, including the commonwealth and carriers, and health care providers, provider organizations and accountable care organizations, which incorporate quality measures into payment terms, including the designation of a set of core measures and a set of non-core measures; (ii) assigning tiers to health care providers in the design of any health plan; (iii) consumer transparency websites and other methods of providing consumer information; and (iv) monitoring system-wide performance.
In developing its recommendations, the task force shall consider nationally recognized quality measures including, but not limited to,measures used by theCenters for Medicare Medicaid Services, the group insurance commission, carriers and providers and provider organizations in the commonwealth and other states, as well as other valid measures of health care provider performance, outcomes, including patient-reported outcomes and functional status, patient experience, disparities and population health. The task force shall consider measures applicable to primary care providers, specialists, hospitals, provider organizations, accountable care organizations and other types of providers and measures applicable to different patient populations.
(b) Annually,not later than July 1, the secretary of health and human services shall establish an aligned measure set to be used by the commonwealth and carriers in contracts with health care providers that incorporate quality measures into the payment terms pursuant to section 28 of chapter 32A, section 81 of chapter 118E, section 108N of chapter 175, section 40 of chapter 176A, section 26 of chapter 176B, section 35 of chapter 176G, section 14 of chapter 176I and for assigning tiers to health care providers in tiered network plans pursuant to section 11 of chapter 176J. The aligned measure set shall designate:(i) core measures that shall be used in contracts between payers, including the commonwealth and carriers, and health care providers, including provider organizations and accountable care organizations, that incorporate quality measures into payment terms; and (ii) non-core measures that may be used in such contracts.
SECTION 3. Section 1 of chapter 6D of the General Laws, as appearing in the 2016 Official Edition, is hereby amended by inserting after the definition of “Performance penalty” the following 2 definitions:-
“Pharmaceutical manufacturing company”, an entity engaged in the production, preparation, propagation, conversion or processing of prescription drugs, directly or indirectly, by extraction from substances of natural origin or independently by means of chemical synthesis or by a combination of extraction and chemical synthesis or an entity engaged in the packaging, repackaging, labeling, relabeling or distribution of prescription drugs; provided, however, that ''Pharmaceutical manufacturing company'' shall not include a wholesale drug distributor licensed under section 36B of chapter 112 or a retail pharmacist registered under section 39 of said chapter 112.
“Pharmacy benefit manager”, a person or entity that administers: (i) a prescription drug, prescription device or pharmacist services; or (ii) a prescription drug and device and pharmacist services portion of a health benefit plan on behalf of a plan sponsor including, but not limited to, self-insured employers, insurance companies and labor unions; provided,however, that “Pharmacy benefit manager” shall include a health benefit plan that does not contract with a pharmacy benefit manager and administersits own:(a) prescription drug, prescription device or pharmacist services; or (b) prescription drug and device and pharmacist services portion, unless specifically exempted by the center.
SECTION 4.Said section 1 of said chapter 6D, as so appearing, is hereby further amended by inserting after the definition of “Physician” the following definition:-
“Pipeline drugs”, prescription drug products containing a new molecular entity for which the sponsor has submitted a new drug application or biologics license application and received an action date from the federal Food and Drug Administration.
SECTION 5. Said section 1 of said chapter 6D, as so appearing, is hereby further amended by striking out the definition of “Quality measures” and inserting in place thereof the following 4 definitions:-
“Quality measures”, aligned quality measures established pursuant to section 16AA of chapter 6A.
“Rate of readmissions”, 30-day, all cause, all payer readmission measure, as determined by the center.
“Readmissions performance improvement plan”, a plan submitted to the commission by a provider organization under section 10A.
“Readmissions reduction benchmark”, the projected annual percentage change in the statewide rate of readmissionsas measured by the center pursuant to section 10A.
SECTION 6. Section 2A of said chapter 6D, as so appearing, is hereby amended by inserting after the figure “10”, in lines 5 and 9, each time it appears, the following figure:-, 10A.
SECTION 7. Section 6 of said chapter 6D, as so appearing, is hereby amended by adding the following paragraph:-
If the analysis of spending trends with respect to the pharmaceutical or biopharmaceutical products increases the expenses of the commission, the estimated increases in the commission’s expenses shall be assessed fully to pharmaceutical manufacturing companies and pharmacy benefit managers in the same manner as the assessment under section 68 of chapter 118E. A pharmacy benefit manager that is a surcharge payor subject to the preceding paragraph and administers its own prescription drug, prescription device or pharmacist services or prescription drug and device and pharmacist services portion shall not be subject to additional assessment under this paragraph.
SECTION 8. Section 7 of said chapter 6D, as so appearing, is hereby amended by striking out, in lines 5 and 6, the words “and (2) to foster innovation in health care payment and service delivery” and inserting in place thereof the following words:- (2) to foster innovation in health care payment and delivery; and (3) to foster innovation in reducing readmissions, including in addressing social determinants of health and improving behavioral health integration.
SECTION 9. Said section 7 of said chapter 6D, as so appearing, is hereby further amended by inserting after the word “organizations”, in line 17, the following words:- , health care trailblazers.
SECTION 10. Section 8 of said chapter 6D, as so appearing, is hereby amended by striking out, in line 32, the words “and (xi) ” and inserting in place thereof the following words:- (xi) not less than 3 representatives of the pharmaceutical industry; (xii) at least 1 pharmacy benefit manager; and (xiii).
SECTION 11. Said section 8 of said chapter 6D, as so appearing, is hereby further amended by striking out the word “that”, in line 92, and inserting in place thereof the following words:- , including a provider organization’s rate of readmissions, that.
SECTION 12. Subsection (g) of said section 8 of said chapter 6D, as so appearing, is hereby amended by striking out the second sentence and inserting in place thereof the following sentence:- The report shall be based on the commission's analysis of information provided at the hearings by providers, provider organizations, insurers, pharmaceutical manufacturing companies and pharmacy benefit managers, registration data collected under section 11, data collected or analyzed by the center under sections 8, 9, 10 and 10A of chapter 12C and any other available information that the commission considers necessary to fulfill its duties under this section as defined in regulations promulgated by the commission.
SECTION 13.Said chapter 6D is hereby further amended by inserting after section 9 the following section:-
Section 9A. (a) The commission shall establish an annual statewide readmissions reduction benchmark. In establishing the benchmark, the commission shall consider: (i) the data collected by the center on hospital and provider organization readmission rates from the 3 most recent years for which the center has data; (ii) the distribution of readmissions volume among provider types; (iii) available evidence on feasible interventions to reduce readmissions rates; and (iv) any other relevant information identified by the commission.
(b) Prior to establishing the annual statewide readmissions reduction benchmark pursuant to subsection (a), the commission shall hold a public hearing and hear testimony from payers, providers and other interested parties. The hearing shall examine state and national readmission rates and trends, rates and trends for different provider types, successful care delivery models and interventions to reduce readmission rates, barriers to successful implementation of such models and interventions and other information identified by the commission. Following the hearing, the commission shall provide a report to the clerks of the senate and house of representatives and the joint committee on health care financing that summarizes the testimony received and the data and information reviewed by the commission to establish the benchmark.
SECTION 14. Section 10 of said chapter 6D, as appearing in the 2016 Official Edition, is hereby amended by inserting after the figure “$500,000”, in line 152, the following words:- the first time that a determination is made and not more than $750,000 for a second or subsequent determination; provided, however, that a civil penalty assessed under 1 of the above clauses shall be a first offense if a previously assessed penalty was assessed pursuant to a different clause. A civil penalty assessed under this subsection shall be deposited into the Health Safety Net Trust Fund established in section 66 of chapter 118E.
SECTION 15. Said chapter 6D is hereby further amended by inserting after section 10 the following section:-
Section 10A. (a) The commission shall, based on the most recent data provided by the center, identify provider organizations that have rates of readmission that are excessive and threaten the ability of the commonwealth to meet the annual readmission benchmark. The commission shall provide notice to all provider organizations that have been so identified. The notice shall state that the commission may require the provider organization to develop and implement a readmissions performance improvement plan.
(b) The commission shall review the performance of the provider organizations identified pursuant to subsection (a) and consider: (i) the trends of the provider organization’s readmission rates; (ii) the payer mix of the provider organization; (iii) the demographics and health status of the provider organization’s patient population; (iv) the status of the provider organization as an accountable care organization or a participant in an accountable care organization; (v) the percentage of the provider organization’s revenue and patient population subject to alternative payment arrangements; (vi) the provider organization’s ongoing strategies or investments designed to reduce readmissions; and (vii) any other factor that the commission considers relevant.
In reviewing the provider organization’s performance under this subsection, the commission shall use data from the center and may seek information or documents from the provider organization or payers.
(c) If after a review under in subsection (b) the commission identifies significant concerns about a provider organization’s readmissions rate and determines that a readmissions performance improvement plan could result in meaningful cost and quality improvement, the commission may require the provider organization to file and implement a readmissions performance improvement plan.
(d) The commission shall provide written notice to an identified provider organization that it is required to file a readmissions performance improvement plan. Not later than 45 days after receipt of the notice, the provider organization shall file: (i) a readmissions performance improvement plan with the commission; or (ii) an application with the commission to waive or extend the requirement to file a readmissions performance improvement plan.
(e)(1) The provider organization may file any documentation or supporting evidence with the commission to support the provider organization’s application to waive or extend the requirement to file a readmissions performance improvement plan pursuant to subsection (d). The commission shall require the provider organization to submit any other relevant information it deems necessary in considering the waiver or extension application.
(2) The commission may waive or delay the requirement for a provider organization to file a readmissions performance improvement plan,if requested under subsection (d), in light of all information received from the provider organization, including any new information, based on a consideration of the factors described in subjection (b).
(3) If the commission declines to waive or extend the requirement for the provider organization to file a readmissions performance improvement plan, the commission shall provide written notice to the provider organization that its application for a waiver or extension was denied and the provider organization shall file a readmissions performance improvement plan.
(f) A provider organization shall file a readmissions performance improvement plan not later than 45 days after receipt of a notice under subsection (b); provided, however, that if the provider organization has requested a waiver or extension, it shall file the plan not later than 45 days after receipt of a notice that the waiver or extension was denied or, if the provider organization is granted an extension, on the date given on the extension. The readmissions performance improvement plan shall be generated by the provider organization, identify the causes of the provider organization’s excessive readmissions rate and include, but shall not be limited to, specific strategies, adjustments and action steps that the provider organization proposes to implement to improve performance in reducing readmissions which may include coordination with a community health center. The proposed readmissions performance improvement plan shall include specific identifiable and measurable expected outcomes and a timetable for implementation. The timetable for a performance improvement plan shall not exceed 24 months.
(g) (1) The commission shall approve any readmissions performance improvement plan that it determines is reasonably likely to address the underlying cause of the provider organization’s excessive readmission rates and has a reasonable expectation for successful implementation.
(2) If the board determines that the readmissions performance improvement plan approved by the commission is unacceptable or incomplete, the commission may provide consultation on the criteria that have not been met and may allow an additional time period, not more than 30 calendar days, for resubmission; provided, however, that all aspects of the readmissions performance improvement plan shall be proposed by the provider organization and the commission shall not require specific elements for approval.